Obamacare 2.0: Judgment awaits

Obamacare is going into effect next year for real — but what happens with President Barack Obama’s signature achievement in his second term is largely out of his hands.

The biggest piece of the law — the expansion of coverage to as many as 30 million uninsured Americans — will begin in 2014. Obama may not say a word about that in his inaugural address. But the reality is, the success or failure of the health care law may define much of his second term, and that legacy is now in the hands of agency bureaucrats, volatile state capitols and employers, not to mention the whims of young uninsured consumers.

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Obama officially sworn in

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Among the unanswered questions: Will the states do their part to make it work, or will they fight the law? Will employers keep covering their workers, or find ways around it? And will young, healthy people sign up for coverage once the individual mandate is in place — or will they skip it and just pay the penalty?

Obama can make sure his administration is ready to implement the big pieces, and defend the law from deep Republican cuts in the next spending showdown. But he won’t be able to do major tinkering if things go wrong. With a divided Congress, and a solid wall of Republican opposition to the law, Congress will be useless if anything needs to be fixed.

The best case for Obama is the simplest one: The law works exactly as it’s supposed to. Thirty million uninsured Americans get health coverage (the upper end of the Congressional Budget Office’s estimates). They can all afford it. Employers, doctors and health insurance companies accept the changes in health care land.

And, of course, no one gets dumped out of their workplace health insurance or pays higher premiums because of the law.

But several major pieces of the law have to fall into place for this best-case scenario. New health insurance exchanges — run by the states or the feds or both — would have to be ready to offer health plans to individuals and small businesses. Insurers will have to accept everyone with pre-existing conditions. To make sure the insurers can afford to do that, the individual mandate would actually have to work in getting young, healthy people to buy insurance.

On top of that, new subsidies will be available, and states will expand their Medicaid programs to cover millions more low-income people.

The chances that all of this will actually happen, with no bumps in the road? Not even people who worked on the law are really banking on that.

“It’s hard to imagine any word other than tumultuous,” said John McDonough, a former aide to Sen. Ted Kennedy and now a professor at the Harvard School of Public Health. “It’s not going to be simple, and people need to be prepared for that.”

For one thing, McDonough said, some states may have trouble adjusting when the pre-existing condition coverage kicks in — since some states that tried the same thing in the 1990s saw big premium increases (though they didn’t have the mandate or subsidies). And every time there’s a problem, he said, the law’s opponents will play it up big time.

But even with all the potential for trouble, Georgetown University’s Sarah Dash says the law will lead to big advances that won’t be fully appreciated until they happen. People with expensive health conditions will be able to get coverage and small businesses will get more affordable health insurance for their workers because the exchanges will “pool” their health costs into a larger group, she said.

“The reality is going to set in that this isn’t the Wicked Witch of the West, and actually, it’s kind of helpful,” Dash said.